Provider Demographics
NPI:1477505873
Name:NGOM, MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:
Last Name:NGOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 SW INNOVATION WAY
Mailing Address - Street 2:
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-2111
Mailing Address - Country:US
Mailing Address - Phone:772-345-8100
Mailing Address - Fax:
Practice Address - Street 1:10000 SW INNOVATION WAY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2111
Practice Address - Country:US
Practice Address - Phone:772-345-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2022-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226026207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine